Healthcare Provider Details

I. General information

NPI: 1114301678
Provider Name (Legal Business Name): MD HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11903 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2623
US

IV. Provider business mailing address

11903 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2623
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-2900
  • Fax:
Mailing address:
  • Phone: 314-739-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberR9C95
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA PERRY
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-739-2900